Dangerous Transitions: Study Shows Discharge Planning Risks

Brown-Williams, Holly, Aging Today

Tomor Bardha, age 74, lives with his wife and near his son Peter and daughter-in-law, Diane. During his inpatient recovery following surgery for stomach cancer, his family felt the need to be present as much as possible to monitor his care. Bardha speaks fluent Albanian and Croatian, but communicates in English at only a rudimentary level. His translators were not readily available and hospital staff changed constantly. At one point, a nurse came to administer insulin; when his family asked why, she checked scribbled notes in the chart and said Bardha was diabetic. In fact, he needed insulin only temporarily because of his surgery. This and other miscommunications caused his family tremendous worry about his care. Of greatest concern was a problem he had developed with painful hiccuping. Despite repeated questions about this problem, Bardha's family members were told, "Hiccups are normal"

Two weeks after surgery, Peter learned in the evening that his father would be discharged the following morning. He and Diane were shocked because their father's condition still seemed acute. They were given no training or information about how to care for "Papa" at home. In the hours before discharge, Peter and Diane were given cursory training on a mechanical feeding tube they were told "would probably be different than the type delivered to the home.'' They felt very anxious about their ability to ensure Papa's safety while managing the feeding tube, monitoring blood sugar and administering insulin shots.

EXPERIENCES STUDIED

The Bardha family's (not their real names) experience was not rare, according to Health Research for Action (HRA) at the University of California, Berkeley, School of Public Health. To better understand the transitional care needs of older adults and their caregivers before, during and after a hospital stay, HRA analyzed the hospital-to-home transitional care needs of elders and their caregivers, assessed the services available to them in four San Francisco Bay Area counties, and examined the needs of selected vulnerable populations to identify potential interventions to improve transitional care. The study, titled From Hospital to Home: Improving Transitional Care for Older Adults, included analyses of peerreviewed studies and secondary data, focus groups with caregivers and providers, interviews with providers and policymakers, and case studies with families and isolated elders.

In the Bardhas' case, one of the more striking failures of discharge planning that HRA researchers encountered, the family received no information about how to manage the complex care their father required and no one assessed either the family's ability or availability to provide care. The sole written discharge instruction was a sheet of paper with the word Tylenol scrawled across the bottom. Peter and Diane felt that Papa was in no shape to be discharged from the hospital, and they had tremendous fear about his care at home. They had no idea that they could have appealed the discharge decision.

Only six hours after coming home from the hospital, Tomor Bardha not only continued to experience violent hiccups, but also developed a fever and felt disoriented. Family members called their local hospital and were told to bring him to the emergency department. An X-ray determined that Bardha had pneumonia, and technicians reconnected him to feeding equipment to provide nourishment. They also gave him an injection of Thorazine, which stopped the hiccups. However, Peter and Diane were stunned when told only hours later to take him home. Given the severity of his father's condition, Peter insisted that Bardha be kept in the emergency department overnight.

Although the Bardhas felt it very premature, they brought Papa home the next day after being reassured that a nurse was scheduled to visit. When the nurse examined Bardha and realized the severity of his condition, she immediately ordered his.readmission to the hospital. …

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